Monthly Archives: January 2017

I arrived early and grabbed a corner spot in the room. Soon, as most everyone has noted, the sleepy residents began to trickle in. A doctor began lecture by proposing “something new.” [I did not get the doctor’s name, unfortunately, because he didn’t introduce himself before and he was busy discussing surgery cases after lecture.] He suggested proposing a trauma scenario and running through it in assessment and care with the residents. He told them that this would be helpful preparation for their boards, and it was really cool to be a part of.

The scenario was a thirty one year-old male in a high-speed MVC (motor vehicle collision). The patient’s vitals were: a systolic blood pressure of 90 (which, he noted, is an ambiguous blood pressure, so it is great practice for the boards) and a heart rate of 110. The leading doctor then cold called various residents to go through the steps to assess this patient in a trauma bay. The first resident claimed that they should assess the airway. To that, the doctor responded “yes” and told the resident that the patient had a GCS of 7. I remembered from pathophysiology that GCS is short for “Glasgow Coma Scale” and is noted as the most common scoring scale for determining a patient’s level of consciousness following potential brain injury (brainline.org). A patient’s GCS can be anywhere from 3-15. A patient receives a number for various subcategories of assessment: Eye opening (1-4), Verbal Response (1-5), Motor Response (1-6). Each number in the subcategories corresponds to the way a patient responds to a stimulus. Any GCS of 3-8 is considered a severe injury. To learn more, you can visit: http://www.brainline.org/content/2010/10/what-is-the-glasgow-coma-scale.html. So, I now know that this patient is considered to have a relatively low GCS. Okay, so back to the resident who decided to assess the airway. At this point, several other residents were chiming in with their own thoughts and ideas. One resident said “RSI!” which I now know is “Rapid Sequence Intubation.” I learned that RSI, a method that uses anesthesia, is the ideal method for endotracheal intubation for patients in the ED because it “results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis)” (emedicine.medscape.com). After the lead doctor asked which drug they should use for RSI, one resident chimed in and suggested that they use etomidate, an anesthetic. The doctor then followed up and asked that drug’s adverse effects. Several residents said “adrenal insufficiency.” The residents seemed to all agree that they should not use propofol or ketamine for the RSI. At this point, the doctor asked about what types of paralytics the residents could push. Several residents said “polarizing or depolarizing.” Another resident suggested using “sux” (Suxamethonium chloride), apparently a short-acting paralytic.

The next step in assessment would be to assess bilateral chest sounds. Another resident chimed in that the next step after that would be to check circulation: central pulse, blood pressure, and access. At this point, the leading doctor asked about what size IV to use. One resident said that the largest bore IV possible is ideal, located in the ACs. At this point, the doctor asked what to do if a nurse brings a “triple lumen” IV. Everyone at the table seemed to know this was a big “no no” and responded that this particular IV should not be used. The doctor asked what to do if achieving a large bore IV was not possible in the ACs. The residents agreed that they should now try for a central line or go IO (intraosseous infusion). If they had to go IO, they would try for the sternum, the humerus (ideal), or the tibia. The doctor asked, “What next?” and one resident responded, “Give blood.” All agreed to begin O negative blood because, as the lead doctor suggested, a main reason for hypotension in trauma is loss of blood.

The residents continued their primary survey and then decided to get a chest x-ray and a FAST, especially because he was involved in a blunt trauma from the MCV. The FAST is short for “focused assessment with sonography for trauma,” and basically means a rapid bedside ultrasound that looks for blood around the heart (pericardial effusion) or trauma to abdominal organs. Then, the residents decided to move into the secondary survey. They found that the man’s pelvis was unstable. After several suggestions about using a pelvic binder to “compress form to tampenade venous bleeding,” there was a short debate about binder efficacy. Another doctor in the room suggested that all orthopedic literature suggests binders for all pelvic fractures. They called this type of binder a “T pod” and discussed proper placement on the greater trochanter for greatest effect. The next resident suggested to do a PAN scan. The doctor then said that the patient’s blood pressure is decreasing and asked what to do. A resident suggested giving more blood. The lead doctor agreed and insisted on not using “crystal light.” (I could have sworn this was a sweet drink found in vending machines, but I think that is what they said!) The doctor said whole blood is best (with a 1:1:1 ratio of RBC, platelets, and (I believe), clotting factors). The residents then suggested repeating FAST, looking for pelvic bleeding, activating DPA, and then potentially ligating the internal ileac vein bifurcation. (Things were moving very quickly at this point, and I was trying to keep up with notes!) The doctor then discussed REBOA, a method that replaces an aortic cross clamp by putting a balloon in the aorta and occluding distal bleeding. However, apparently this procedure takes a while and would not be ideal for an immediate trauma.

Surgery 1: OR3, Abdominal Ex. Lap. Fascial Closure, Dr. Sadjadi

I arrived in OR3 to see a patient on the table with most of his small intestine visibly exposed. A sweet doctor came in and explained what was going on with this patient. He said he’d been stabbed and had significant damage to his liver. He had already had one round of surgery, but explained that the patient would likely need several more to get his “guts” back in and close the wound. Basically, in the crudest of terms, the surgery was attempting to push the exposed organs back in and sew the man’s abdomen up partially. I was eagerly welcomed to view the surgery and everyone was very friendly. I was really impressed with how all the doctors approached the surgery with such humility. They asked questions of each other and talked about decisions being made, all without a hint of ego. One doctor asked if the other was going to excise the liver. The lead surgeon said that he would not because the liver was mostly dead and he was worried about bleeding. With the help of a resident, Dr. Sadjadi made stitches in the fascia, alternating the top and bottom of the approximately foot-long opening. It was almost like a corset closing, but the organs inside were so inflamed, so it was not possible to fully sew the man up. One resident worked to push the organs back in while Dr. Sadjadi continued his stitches. At this point, the team took out the rag that was covering the organs and put in a plastic sheet, then covered that with wet gauze, and then covered with something called an “ioban” sheet, which I assume is to keep the area as clean as possible. One doctor asked Dr. Sadjadi how he knew if the skin was close-able. Dr. Sadjadi said it is a lot about how the skin feels, its turgor. The surgery was relatively quick, from 8:23-9:02. On the way out, Sarah Bradford, a kind resident, took me under her wing and allowed me to follow her into the next surgery, which was already underway.

Surgery 2: OR6, Female ejected from vehicle, two broken legs, one dislocated right knee, questionable pulse in right foot (potentially from an occluded popliteal artery)

Dr. Bradford helped me put on my “leads” because there were many x-rays occurring in this patient’s room and we needed to protect our bodies from radiation. The first thing I noticed when I walked in was a doctor literally power-tool drilling into this patient’s femur. I learned that these drills would be essential in setting up the “external fixation system” (shown below) that would stabilize this woman’s bones, which had been broken in multiple places.

Throughout the drill process, an x-ray technician took multiple shots of the bones in her legs and her knee. She had dislocated her knee in such a way that many of the doctors said they had never seen before. Apparently, the dislocation not only tore her ligaments, which is to be expected, but it also sheared off the top of her tibia (I think). The doctors were concerned about this because it would affect her cartilage as well, and lead to a long recovery.

Interestingly, the woman came in with what I understood to be a weak or absent pulse in the foot. I learned that bones must be realigned or vasculature can be occluded, so that’s why the doctor was working on the bones before addressing the vasculature. I think, from what I understand, realigning the knee helped the pulse come back in the foot. The doctors used a doppler machine to find the pulse in the foot.

While this was occurring, a few people were working on closing up gashes on the woman’s head and forehead and shin. I watched them irrigate and prepare for suturing. I also got to watch them close up the gashes. As I listened to some doctors discuss her forehead wound, they mentioned that she would likely have a large scar. Apparently, when she got in her accident, she hit her head in a way that removed a big chunk of tissue, so it would be difficult to close the tissue (1), and it would heal in a way that went against natural collagen fibers (2).

This lady has a long road ahead of her, which made me feel sad, but I realized that all of these people were helping her take that first step. It was really an honor to be a part of the day.

The day of my first OREX shift, I got up at 5:15 hoping to shower and get ready without disturbing my family, but no dice. My 6-year-old woke up loud and full of energy, ready to turn on all the lights and welcome the day. Luckily I had kid-interruption time built into my morning schedule, so I still made it out the door in time to reach my favorite coffee place before they opened at 6:30. I bought a quick coffee and forced myself to have a bite to eat before heading to Highland. I got to OA2 a few minutes before 7 and grabbed a seat at the table, determined to get the most out of the experience. Dr. Harken arrived a few minutes later and started his lecture with a broad question: Why do we treat the same symptoms or presentation differently in different patients? He gave a few hypothetical scenarios where the patients differed in age, health history, and reasons for coming to the hospital. The lecture was interesting, but for the most part over my head. I was able to follow a little of it by reaching back into the depths of my memory from my time working as an EMT in college…pneumothorax, I know what that is!

After the lecture, I introduced myself to Dr. Harken who looked for a resident to walk me up to the OR. The only person going up was an intern who seemed like he was in a rush and not particularly thrilled to have me in his charge. We walked up to K5 together, and he left in a hurry after showing me where the card was to get my scrubs. It was exciting to suit up in official hospital scrubs for the first time. I looked at myself in the mirror and felt giddy just looking like a doctor. I wondered if the surgeons I would be observing felt any of that excitement still, or if it had become totally rote to them.

With my scrubs on, I made my way to the board to pick out my first surgery. It was a little daunting, but I picked a procedure that sounded promising…only to find that the assigned OR was empty. Not wanting to attract attention by walking back to the board, I went into the first room I could find where a surgery was getting set up. The patient had fallen and gotten a compression fracture in their thoracic spine, so the doctors were going to fuse the vertebrae — the exact procedure my grandmother had just a week or two ago! I was stoked to watch and tell my grandmother about the experience, but unfortunately, the circulating nurse told me they wouldn’t be getting started for half an hour and recommended I come back then.

Although I really wanted to see that surgery, I didn’t want to stand around for half an hour arousing suspicion, so I ducked into another room where a different surgery was being prepped. This operation was a proctectomy (removal of the rectum), ileal pouch anal anastomosis, and diverting ileostomy. I didn’t get a full run-down of the patient’s history, but my understanding was that he had had an ileostomy placed previously because he suffered from diverticulitis. In recent months another doctor prescribed high dose ibuprofen for the patient’s back pain, which led to the development of a perforation in his bowel. From what I could tell, the gist of the surgery was to reverse the ileostomy, remove the rectum, and reconnect the remaining tissue to his anus to restore gastrointestinal continuity.

There were four doctors on the floor from the beginning of the surgery and a few others who came in and out at various points. Dr. Miraflor seemed to be in charge of everything. I didn’t catch the other doctors’ names, but there was a senior resident who led the surgery with Dr. Miraflor instructing and advising him, as well as a junior resident and an intern. An OR tech assisted the surgeons at the table, handing them tools, helping them with their gowns and gloves, keeping track of supplies, and coordinating with the circulating nurse. We chatted a bit and she shared an interesting fact about the blue loops on the lap pads. I had assumed they were there just to visually detect the laps, but she explained that they’re actually radiopaque, which means if one is missing and the docs can’t find it, it will show up on an x-ray. Crazy!

The surgery began with the doctors detaching the ileum from where it had fused to the patient’s abdomen. This was a long and meticulous job; Dr. Miraflor described and modeled every move for the senior resident. She mentioned repeatedly how critical it was that they avoid accidentally cutting through the intestinal tissue. It took about 90 minutes and was done almost entirely by the senior resident.

Once the intestine was completely free from the abdominal wall, the doctors used the device shown here called a proximate linear cutter. It clamped around the end of the intestine, simultaneously sealing it and cutting the excess tissue off. It looked vaguely similar to the end of a tube of toothpaste when it was finished. They pushed the sealed ileum through the hole in the abdominal wall and moved on to the next part of the procedure.

The doctors started by making a midline incision from the patient’s sternum down to his pelvic floor, curving around the umbilicus. Once they had the patient open, Dr. Miraflor was dismayed to find that his intestines and mesentery were “all tangled up.” He had a lot of adhesions and so instead of the intestines being one long loopy piece, sections of it were held together in a jumble by thin membranes that all had to be carefully cut with the bovie. Apparently adhesions are a fairly common result of abdominal surgery, so these likely formed when the patient had his ileostomy put in.

At this point, it became a little hard for me to see because most of the work was being done deep in the patient’s abdomen. There were five or six people around the table, so I couldn’t visualize much and had to go by what they were saying. After removing all of the adhesions, the doctors carefully dissected out the rectum, removing a piece that was roughly 8 inches long. As they were completing this stage of the procedure, the senior resident stepped away from the table for a moment and began quizzing me about rectal anatomy. I tried to stammer out some answers, but Dr. Miraflor told him I wasn’t a med student and had no reason to know anything he was asking. I have to admit I was a little disappointed — I don’t know much anatomy, but I was happy to make some educated guesses and be wrong.

Although there was a lot I couldn’t see or make much sense of, I read a little about the procedure at home afterward and learned that after removing the rectum, reversal of the ileostomy involves using a section of the small intestine to create a pouch that will serve as a reservoir for stool — essentially recreating the function of the rectum. I couldn’t see this happening at all, but several hours in, the docs announced that it was done. With the ileal pouch made, they were ready to move forward with the anal anastomosis.

In order to attach the anus to the ileal pouch, Dr. Miraflor planned to use an end-to-end anastomosis (EEA) stapler shown here.

The doctors were getting ready to do that when they found that the staples closing the end of the anus had come out (or hadn’t fully set in the first place). Things immediately got very tense. The surgery had been going on for several hours with no break, and everyone had assumed they would be wrapping up in about an hour. Now it seemed clear that was an unrealistic expectation, but in the absence of any idea about what went wrong, the timeline became muddy. The only explanation anyone could think of was that one of the staplers had malfunctioned and they hadn’t noticed for some reason. Dr. Miraflor called Dr. Victorino, one of the attendings, and they had a hushed and somewhat anxious conversation about what to do. She decided to try to sew a purse string around the section where the staples had come out for fear that if they tried the stapler again, they would risk ripping apart the tissue. Despite her best attempts, the purse string didn’t work, and everyone’s anxiety levels continued to rise. As they tried to come up with another solution, Dr. Miraflor kept updating the anesthesiologist, “Okay, it’s going to be at least another two hours,” and he kept assuring her everything was fine.

Finally, Dr. Victorino decided to scrub in and assist with the surgery. Initially he sat between the patient’s legs (which were in stirrups) and physically pushed on his perineum to give the doctors working in the abdomen a little more access to the internal end of the anus. After the purse string failed, they decided to try a contour stapler, but it wouldn’t fit around the Allis clamps holding the end in place.

This led to another meticulous (but creative!) task where they individually placed ~25 loops of prolene thru the end of the tissue, each with a clamp hanging off of it. Once they were all in, which took about half an hour, one of the attendings pulled all the threads taut and Dr. Victorino was able to get the contour stapler into place. It seemed successful and everyone started to breathe a little easier.

As they prepared again to do the anastomosis, Dr. Victorino went down to the patient’s anus and reached inside to determine if the staples were holding. Dr. Miraflor reached down to the stapled area from inside the abdomen, and all of a sudden they realized they could feel each other’s fingers. There was a lot of cursing then, and Dr. Miraflor resigned herself to the fact that she would have to be there for another several hours. At this point I had to leave to go to class so I didn’t get to see how it all resolved. As I was leaving, Dr. Victorino called in Dr. Bui, another attending, to fill him in and hear his opinion. Dr. Miraflor spoke to Marisal, the circulating nurse, to give her a list of the tools and equipment she needed for the ensuing procedure. Everyone was upset and exhausted, so it seemed like a good time to call it a day.

UPDATE: Apparently the surgery continued until around 7 pm, a full four hours past when I left. See Cici’s Day 1 notes for the end of the story!

I arrived early for my first OREX shift in order to get situated on time. A few residents arrived early then the rest poured in, just moments before Dr. Harken came in. He immediately began with (hypothetical?) case studies for the senior residents to discuss. Quite complex cases that they had to figure out how and what to treat on the fly. I grasped much of it, but plenty of it was beyond my learning. Only the senior residents partook while the others listened.

One 3rd year medical student sat next to me. She said. “Are you OREX?” Why yes.

“I was too” she said. WHATTTTT!!!!!

Alexis Colley is a 3rd year medical student at UCSF, and is now doing a rotation at Highland. She had previously volunteered in the ED for 3 years and participated in the OREX program 5 years ago.

I politely asked if she could show me the ropes in the OR and she immediately said ‘Of course! Someone showed me the ropes on my first day and I’m happy to show you”. I felt the first day jitters fading. Then she added, “If you want, you could come to the surgeries that I’m partaking in with Dr. Russell (3rd year resident) and Dr. Harken. I jumped on that as fast as I could. But before I could say “Yes Please!” she had introduced me to 2 other residents who had interesting surgeries planned as well.

I got into the OR for surgery #1, installation of a porta Cath. A porta Cath provides chemotherapy access directly into the aorta. Dr. Harken, who somehow already knew my name, told me that it is a preferred manner by which to deliver chemotherapy drugs as they can cause great damage to the tissues of the arm thru a peripheral IV.

I had some familiarity with the device going in to the surgery but was intrigued to see how it would be placed. Dr. Harken, who is truly an amazing teacher, insisted that I get up right next to the ultrasound screen and the patient, to watch.

Alexis tried a number of times to get the needle into the vein, but it kept collapsing. after a few minutes. Dr. Harken said “This is almost impossible. I don’t know if I can even get this one. This is not fair for you Alexis”.

She had just about got it, but handed it over to Dr. Russell.

He then manipulated the needle into the sub-clavian vein. Dr. Harken then slid a guide wire into the vein, then the expander. They made a second incision point where the port would be implanted and the tube that would carry the chemo to the aorta.

Once the bulk of the surgery was done, leaving the stitches to the resident and Medical student, he said “C’mon Terry, let’s go see what other surgeries are happening before our next one.” We went onto OR 1 and there was laparoscopic myomectomy going on. This patient had a broken T 12 vertebrae that they were trying to stabilize with pins and screws

Then we went to see a laser Lithotripsy (laser breakdown of a large Kidney stone). Dr. Harken told me watch either one of these for a while and come back to OR3 in 30 minutes.

I returned to the surgery in OR3 just as it was to begin. This was a AV fistula being placed. An AV fistula is the joining of the cephalic vein with the brachial artery in order to make a better access for Dialysis. It is a meticulous vascular surgery. An hour and a half later, it was stitch up time.

As the surgery was completed, Dr. Harken asked for a “sleeve” from the OR tech. I didn’t know what this surgical implement was or how it would installed. A moment later the OR tech Asked for my right hand, pulling a sleeve on me and gloving me up. “I want you feel the thrill” said Dr. Harken. A thrill is a buzzing sensation felt under one’s finger upon palpation at the location of a AV Fistula. I had felt one in nursing clinicals previously, so I had some expectation of what to feel. I was amazed to have had the opportunity to feel it immediately post-surgery.

An AV fistula takes about 6 weeks to “mature”, or until it is ready to be used.

The third surgery I saw was truly sad and very intense. It has taken me some time to try to process it, and it is likely to have a very strong impact on me for quite some time. The patient was a multiple gunshot victim who had been in ICU for about 10 days. In order to keep her alive, they had used many medications including Levophed/Norepinephrine to vasoconstrict her blood circulation in order to maintain cardiac output and blood perfusion to her brain, heart and organs. This drug is usually used after severe hypotension or shock. One very dangerous side effect of the drug is that there can be decreased perfusion to the extremities due to its vasoconstrictive action, ischemia results and necrosis can occur.

After the patient was brought in, everyone in the room was noticeably affected by the condition of this patient. This was described to me as a “life or death surgery”. The head resident, Dr. John Swanson, said to me “You are now seeing the horrible side of the marvels of modern medicine”. The tragedy of this person’s situation was felt by every single person in the room. (2 surgeons, 4 residents, 1 third year med student, 2 CRNA’s, 1 OR tech, 1 OR nurse). Both hands and both feet needed to be amputated to give the patient any hope of survival, as necrosis had affected all of her limbs. I will not go into the details of the surgery, but it was not an easy thing for anyone in the room.

The head resident again spoke with me to warn and prepare me. “Have you ever witnessed anything like this?” No, I responded. He said “Just be careful because we have had people faint in these procedures.” I took extra precautions and positioned myself at a distance and paid keen attention to my own reactions. Thankfully, I did not faint. It was intense but I did watch, and after the initial amputations, I did watch the bandaging and cauterization fairly closely. Afterwards, there was a somberness in the room I will never forget.

From my experience volunteering at Highland in the ED, I have seen many victims of senseless gun violence. Every single victim has some effect on me, but the impact that this patient had on me is profound.

November 23rd, 2016 did not go as planned, but was so much more than what I had expected. I was a nervous and excited wreck when I arrived in the conference room at 6:45AM. I was finally able to calm down, when a doctor comes in and asks if I were here for the morning conference. I answered with a yes and was about to do the whole OREX student spiel because I thought he was suspicious of me. However, he told me that the meeting was replaced with a larger conference in some classroom and he did not know where or what room number it was, so I ran out of the room with five minutes left until it the stroke of 7. I vaguely recalled my Highland volunteer orientation two years ago, which was held in the only classroom I knew of at Highland. Luckily, I was right and managed to find the room in time before I interrupted Dr. James Betts from Children’s Hospital as he began his lecture on pediatric trauma and emergency care. I had expected twenty people tops, but there were the usual residents and interns, as well as Children’s staff and Highland applicants. By the time I found a seat, my heart was racing and my hands were shaking as I lifted my coffee to my lips. Dr. Betts discussed the general protocol and procedures in pediatric care and shared many heartbreaking and encouraging cases. It was inspiring how dedicated he is to his work.

After the lecture finished, I located Dr. Harken from a distance, but some medical students or applicants beat me to him. It was also already 8:30, so I made my way to the OR by myself. I was a bit disoriented and since I was already sticking out like a sore thumb, I just asked people in the hallway where things were and was able to successfully change into scrubs. And with my luck of course, all of the surgeries on the whiteboard were scheduled for 8AM. I was a little bummed and lost. As I made my way to pre-op and post-op to search for something to do, charge nurse Nathan spots me and was very nice in asking me who I was. He then brings me to OR 3 and introduces me to the staff. It was a colostomy takedown performed by Dr. Bullard (I believe) and Dr. Gupta. I was quite nervous, but Dr. Gupta was playing music and ‘No Scrubs’ by TLC came on and it was very fitting and just perfect.

I missed the first part of the surgery, when they opened up the artificial opening for the colostomy bag. One of the nurses, Romal was very chatty, welcoming, and willing to answer any questions I had. They began opening up the patient’s abdomen. “The Lamborghini of retractor sets”, which referred to a gold self-retaining retractor set that attached to a bedpost, was brought in and set up to hold open the abdomen. I wasn’t the biggest fan of the contraption, as it was blocking my view of the anatomy. Romal thoughtfully asked if I wanted to observe a more interesting surgery multiple times, but I politely declined as I did not want to interrupt another surgery and I already thought this surgery was very interesting, since it was my first surgery ever. After an hour or two of abdomen work, Dr. Gupta repositioned to the patient’s anus and prepped to use an endoscopic curved intraluminal stapler, which she referred to as “the most stressful part of the case”. During this brief transition, Dr. Bullard was super nice and walked over to me to introduce herself personally. I stuck my hand out to shake her hand, but quickly pulled back as I realized I was not sterile. Dr. Gupta then inserted the stapler into the patient’s anus and with very precise coordination with Dr. Bullard, who viewed the instrument from the abdomen, the staple reconnected the intestines. Dr. Bullard then calls me over to the operating table to take a look. In my head, I was screaming to myself repeatedly, “DO NOT FACE PLANT INTO THIS MAN’S JEJUNUM” (not quite sure why specifically the jejunum). I’m sure everyone else thought I was way too close to the sterile blue; the scrub tech told me to take off my badge and Romal was even pulling back my oversized scrub sleeve, but Dr. Bullard told me to get even closer, so I wasn’t going to say no. She pointed out some of the anatomy and the staple in the distal sigmoid colon. The only abdominal anatomy I had seen prior to this was in a two year old cadaver. It was really amazing to compare and apply what I had learned before to a live human body. They ended up having to redo the staple because it was not completely sealed, then they closed the abdomen and removed remnants of the ostomy from the colostomy opening.

The first surgery wrapped up around 12:45PM. Scrub tech Ana Maria asked if she could show me around the department. It was a great relief as there were no other surgeries scheduled until 2PM (I should have actually used this time for lunch, but I got too excited). She told me about her occupation as a contract technician and taught me about all the protocols, procedures, and many many instruments used during and in preparation for different surgeries. We took a quick break for some water, then I helped her prep for another rectal case. The patient came in just on time and was in a lot of pain. I really wished to help comfort him, but he only really understood Spanish. As they positioned him and his groin area was exposed, so was the most vile smell. Nurse Romal was a lifesaver and put toothpaste on our face masks.

Dr. Gupta led a group of residents in an EUA (exam under anesthesia) and perineal debridement. They reassured me that this case was not normal and was exceptionally bad. The patient had a necrotic rectal cancer as well as a crazy infection. I was asking myself what I was looking at; his anatomy was quite disfigured. Under his scrotum, were two openings (yes, two) with greenish-grey “stuff” coming out of them along with some blood and below that, a baseball-sized mass in his gluteal cleft. It was quite the sight. Dr. Gupta started just feeling around, and pieces of dead flesh just fell right off. The doctors were aware that it was impossible for them to extract all of the cancer, so they aimed to clear out as much of the infection as possible for the comfort of the patient. The procedure was much quicker and less precise than the previous operation. The doctors simply cranked up the Bovie to maximum power, cauterized everything, and extracted anything that was dead or infected. I was amazed by Dr. Gupta and the other residents and how they got down and dirty, literally. All the other staff were barely able to handle the smell, let alone having the cancer be a foot away from their face. When the doctors were finished, the two holes were opened to form one large hole and it was large enough to easily fit my fist in to. Urologist Dr. Blaschko then used a Cystoscope (small camera on a thin tube that is inserted into the urethra) to visualize the inside of the bladder. It was expected that the patient with such an extreme form of rectal cancer would show signs of bladder cancer; however, the cystoscope was nondiagnostic and “suspicious”. They dressed him in a wet dressing and some mesh underwear before sending him to the ICU. Unfortunately, ICU beds were also all full, so he was sent to the PACU for close observation.

My terrible ankles were dying by 4:30PM, so I thanked all the staff for their kindness throughout the day as they left for the PACU and excused myself. Ana Maria and I further discussed how crazy the last surgery was and she shared some of her other extreme cases, as we got ready to leave together. She was so very kind and even thanked me for letting her show me around, when she was the true lifesaver. She also told me to tell all of you that if you want someone to show you around, just ask for Ana Maria!

As I stepped out of the hospital, I noticed that the sun was setting and the sky was about the same shade as when I arrived in the morning. I realized that most of the doctors inside probably missed all of the daylight. Their energy and resilience are incredible. I was just standing and I was exhausted. I am glad how everything went on my first day and I can’t wait for what else I will experience this next year!

My first day of OREX started off nerve wrecking, as with most experiences that are new. I recall packing my food the night before and making sure I had plenty of rest. Surely, I will not go down in the history of OREX as one of the students fainting on their first day, not that there is anything wrong with that…it’s that it just isn’t my style. Hah, I kid. The goal for the day is to just get comfortable around the OR and not get too ambitious with trying to see too much in too little time. Above all else, bring minimum attention to yourself and if all fails, use the magical words, “I’m one of Dr. Harken’s students through the OREX program.” The plan worked and I felt the entire day was smooth sailing…except at one point which I will go over later.

So I arrived in OA2 at 6:40am just so I can find my cozy spot in the corner. In retrospect, I would advise to come at 6:55 since there was plenty of space. The other residents filed in and hung out in their little groups, going over cases that they are managing. Dr. Harken made his appearance shortly thereafter and gave a presentation on an article about the success rates of old vs fresh blood. The data was presented in a scientific and statistical fashion, breaking things down into quantifiable subcategories that we can use to judge for ourselves. Throughout the presentation, I never felt that he was trying to push an agenda but rather allowed us to take the information in and interpret it for ourselves. An example was how he would ask us, “Why, why why? What does intuition tell you?” I guess my medical intuition wasn’t up to par because a lot of the material didn’t make me automatically jump to any conclusion. I felt inspired though, and hope that one day this information will come second nature. After the meeting was done, I introduced myself to him and he paired me up with a resident name Eric to go upstairs.

We went up and I changed into my scrubs, put on my cap, mask, and booties. Eric showed me to the board and we looked at the upcoming surgeries. I saw one that starts at 8 and it was a Right Hip Arthroplasty. He told me that it might be a cool surgery to check out but wasn’t one that he was going to do…so he took off, leaving me to my own demise. I walked into OR1 and knocked on the door, asking them if it was OK if I can stand in the room. The two nurses looked more confused than me and asked me who I was. I felt now was the appropriate time to use the magical words, “I’m one of Dr. Harken’s students through the OREX program.” One of them nodded and said it would be great to have me. I went over to the board and wrote my name down under medical student. Onto the juicy details of the surgery itself.

The patient was sitting up on the operating table and getting some medicine through the spine by the nurse anesthetist. Her name was Kay and she was showing a first timer resident what she was doing, such as intubating the patient with her laryngoscope. The circulating nurse, Marisal, was running around the room and prepping everything before the doctors started. At first, they didn’t engage with me much, which is understandable. I definitely wanted to be that invisible fly on the wall. I think that after I expressed some curiosity with the things they were doing, their lack of engagement went 180 degrees and they became my saviors in the room! Marisal basically took me around throughout the day and showed me everything she was doing and answered any questions I had. For example, she put a Foley catheter on the patient and explained that it’s advisable to place this on patients if the procedure may go beyond 3 hours. I didn’t get to do it myself but I am sure that if asked, I can do this for future patients. You never know when this skill may come handy.

The preparation took a lot longer than I thought (about an hour) and finally, the doctors came in to begin the procedure. Surprise surprise surprise, one of the residents popped his music on and we were listening to hip hop music in the backround. I guess they got to stick with the theme of being hood since it is Oakland after all. Dr Shah was the attending physician, supervising over Dr Nguyen and Dr. Jerald as they took the reins on the actual procedure. They called the operation at 9:00am and made the first incision, slicing into the right hip of the patient. Marisal got me a stool and allowed me to stand literally at the foot of the patient. I made sure I was able to get a good view as Dr. Shah was 2 feet to my left and the operating residents were 4 feet in front of me. As Dr. Nguyen cut into the fascia and muscle, Dr. Jerald assisted and held the tissue open so that the field of operation can be easier to work with. Throughout the procedure, Dr. Shah gave advice to help Dr. Nguyen so that her operation can go easier. He was very chill and has an easy going demeanor. When he saw that Dr. Nguyen did not need help, he engaged with me and asked about my educational goals. I felt comfortable conversing with him and even went into depth about the procedure, such as why certain cuts are used with a scalpel and some are used with a Bovie (an instrument that cauterizes the flesh to prevent bleeding). This was interesting because in the background, Dr. Nguyen was sawing off the head of the femur and hammering in new instruments. I even had to get a face shield because I was afraid of having some bits of flesh or bones hit my eye (luckily nothing did).

Two hours into the operation and the finishing touches are done. The final sutures are made on the patient and it’s astounding how just a few minutes earlier, his femur was jutting out in the open. I noticed that my questions were going off at a much higher frequency at this point. Perhaps it’s because I was comfortable and the doctors were fine with answering any questions I have. There is always a fine line between being curious and being an added burden to the operation and I made sure to stay within the confines of what is appropriate. I do have to admit though, that I thought it was totally awesome that Dr. Nguyen methodically answered my questions even DURING her live procedure so more brownie points to her. One cool fact that I learned was how after they sutured up the hip, they placed this “glue” material called dermapin or something which seals up the wound. Apparently that small seal costs $500 bucks, which killed me a little inside. After the procedure, I was able to catch up to Dr. Nguyen a little bit and we chatted in further detail about her experience in medicine. She asked me if I was going to sit in on her next operation which was an ankle surgery but I was starving. I felt that this was a good time to head out and so I excused myself. I went to find Marisal and Kay to thank them for holding my hand throughout the day.

As I left the OR1, I felt a sense of inspiration overcome me recounting on what I just saw. I am sure that when the time comes for me to do anything close to this caliber, it would be absolutely terrifying. In that regard, being in OREX and increasing my exposure to the unknown diminishes my fear of what I don’t know. I took off my cap and mask and tossed it into the trash and began walking back to the changing room…

It was at this point that a small Asian nurse walking in the hallway (I didn’t get her name) stopped me in my tracks and asked me where my mask and cap was. I told her that I tossed it in the trash and was heading to the changing room. She must have sensed my weakness and closed in for the kill, asking, “Wait…who are you?” I felt it was appropriate to respond with, “I’m one of Dr. Harken’s students through the OREX program.” She sighed and lectured me about the rule of wearing a mask past the red line. I apologized and said I wasn’t going to do it again. I guess you can’t win it all. It was at this point that I decided to end the day and head to grab some grub since I didn’t eat anything since 7.

My First OREX experience was definately one to be remembered! Even though I was not feeling hungry due to nerves, I forced myself to eat breakfast. This ended up being a very good idea as both of the surgeries I watched were quite long. I arrived at the conference room around 6:50am, and mustered some bravery to sit at the table. The medical students/residents were very friendly as they trickled in, but I could tell they were a little curious who I was.

Dr. Harkin’s lecture discussed different case studies on statins, a class of drugs prescribed to help lower blood pressure. All of the studies found that statins were beneficial for those who took them, even people considered healthy. It is believed that statins work by blocking the liver enzyme essential for the creation of cholesterol; however, Dr. Harkin pointed out that there isn’t a lot of research verifying this mechanism. The question that he kept asking throughout the lecture was “if we do not understand why something works, is it ok to prescribe/use it on our patients?” My gut reaction to this question was initially “no,” but on further consideration, I’m not sure if there is a correct answer. It is the goal of practitioners to improve their patient’s health. If a drug is effective, then there is a potential that you are not serving the patient by withholding it even if its mechanism is not fully understood.

There were a lot of layers to this lecture, many of which I didn’t understand and it seemed like this was a topic they had been discussing for a while. In the end, Dr. Harkin asked if anyone would be willing to take statins themselves, to which the the room’s unanimous response was no. He wondered aloud: “If we are not willing to take statins ourselves, is it fair to expect our patients to?”

After the lecture, I quickly introduced myself to Dr. Harkin and he paired me up with Dr. Mihir who took me to the OR and helped me get my scrubs. The first surgery I watched was a modified radical mastectomy of the right breast performed by Dr. Godfrey and Dr. Fer. Dr. Godfrey asked if I wanted to scrub in and I jumped at the opportunity. Dr. Fer taught me how to do it properly, and the surgical tech Ana Maria taught me how to put on the gloves and gown. I was invited to stand directly next to the patient on a stool, the circulator Ramnik put some glasses on my face, and the procedure began. This was an amazing team of people to have my first OREX experience with. They were all very welcoming and very good teachers. If you can watch one of Dr. Godfrey’s surgeries do it! It’s obvious he loves teaching, and he got me involved at every opportunity. Throughout the surgery Ana Maria taught me names of different tools. Off the top of my head here are a few I remember:

The Bovie, which both cuts and cauterizes tissue.

Army-Navy retractor, used to retract tissue.

Jackson Pratt (JP) drain, used for drainage from site of surgery

The surgery took about 2.5 hours, most of which was spent cutting the tissue down to the muscle using the bovie. I learned that because this patient had relatively large breasts the surgery would take a little more time and would be a bit more difficult than if she were smaller chested. Dr. Godfrey expressed the importance of using the bovi in a “long sweeping clock motion” which I understood to be much easier said than done as Dr. Fer needed a lot of reminding. They were careful not to cut too close to the skin, and to go around the port previously placed for radiation. Dr. Godfrey explained it is important to cut out the tissue 2 cm from the edge of mass because cancer cells like to “spread out”. It was decided not to spare the nipple because the patient was in her 70’s and suffered from dementia. After all the tissue and “bad” lymph nodes were removed, Dr. Fer placed two JP drains before closing the patient up.

Something interesting Dr. Fer told me is that historically 95% of the surgical cases at Highland come in through the ED. This is because many people are uninsured and use the ED for their primary care needs. Just recently, there has been a decrease in this number, and it is believed to be a result of increased insurance rates due to the affordable care act. He expressed concern that this trend would soon be ending as Trump has promised to repeal the affordable care act.

After a quick snack, I ran into Dr. Mihir who offered to take me into a laparoscopic kidney and ureter removal. Even though the surgery had already started, Dr. Mihir ensured me it was fine that I join. He introduced me to Dr. Yamagochi and her team who welcomed me in and offered to answer any questions I had. This surgery was very different than the mastectomy in that all the work was being done internally and a camera was used to navigate. Because I missed the beginning, I am not sure of the initial steps, but when I entered the doctors were working on cutting the main artery to the Kidney. Dr. Yamagochi explained that you must stop the supply of blood to the kidney before cutting off the outflow so that the kidney does not explode with blood.

This surgery was also different from the mastectomy in that there was no resident, so there were very few teaching moments. While the surgeons were very friendly and open, I was feeling a little tired from the last surgery so I didn’t ask as many questions. Because of this, I was not entirely sure of everything that was going on, but I was very happy just to watch. At one point the air that was being used to distend the patient’s abdomen traveled up to the their face causing them to swell. This concerned the anesthesiologist who suggested turning the air pressure down and elevating the head. The doctors tried this approach and it seemed to alleviate the problem. This surgery was much longer than the mastectomy, about 5-6 hours, and even though I didn’t watch the whole thing by the end of it I was exhausted! I politely thanked the doctors and excused myself as they were closing the patient. It truly amazes me how much patience and stamina surgeons have.

I ended my day around 4pm, and overall it was a wonderful first experience! Everyone was so friendly, and I didn’t embarrass myself once! On a side note Lucy was right when she said that you will know RN Judy when you see her, she needs no introduction. Dr. Godfrey said she was in the Navy Seals and I’m not sure if he was joking, but everyone agreed it would make sense. Wishing everyone who hasn’t had their first day yet good luck!

My first OREX day was Thursday, November 17. It was awesome! I saw a craniotomy, cataract removal, ankle draining, and a laparoscopic gallbladder removal.

I got to Kaiser Oakland for Grand Rounds, enjoyed a free breakfast burrito, and listened to a few residents give their presentations. The first presentation was “Does Surgery Stimulate Inflammation?” (apparently it does); he summarized the immune and endocrine response to surgery. One new term I learned is “third-spacing”, which is fluid shifting into interstitial spaces; surgery typically involves blood volume loss, so (as I will discover later) the amounts of IV going into the patient and the urine produced after are recorded to monitor fluids.

The next resident briefly talked about Ella Wheeler Wilcox, a poet who outlived her children and husband, and read her poem “Solitude”.

The final two presentations were the pros and cons of using statin and aspirin during surgery. Both presentations cited the Jupiter trial and Poise-2 paper, and mentioned Dr. Poldermans (a doctor that fabricated data for many papers). Overall, it seems that statins do not significantly harm patients during or after procedures, while aspirin marginally does.

Grand Rounds was over around 8 am.

At Highland, the first surgery I observed was a craniotomy! I walked in to see the patient already unconscious, on her side, and head in a clamp. It was unexpectedly fast; the surgeon, Dr. Patel, dictated the patient information before starting and predicted that it would take about an hour and a half (and it did). The patient had meningioma. He has able to pinpoint the tumor location by using a reflective tool to create a 3D model of the current head and compared it a recent MRI. He sliced through the iodined scalp, drilled and picked a small (~3 inch diameter) circle in the skull, removed it into a bucket, and used an ultrasound tool to cut through the brain matter. The white tumor he removed was about the size of a grape and probably benign. Dr. Patel filled with a white material then a blue liquid plug that mimics the cerebrospinal fluid. The skull flap was polished and had metal brackets attached to it so that the piece can be screwed to the rest of the skull. Then the scalp was sewn, stapled, and wrapped.

The patient’s urine was collected to measure the patient’s fluid loss during the procedure.

The cataract removal was performed by a resident. The patient was responsive and draped throughout the procedure and put under a microscope. The surgeon dropped in a liquid onto the eyeball to keep the eye dilated and injected anesthesia under the eye. He cut a few slits around the iris and injected a blue dye into the eye to stain the capsule surrounding the cloudy lens. He removed a part of the blue capsule, and the lens surfaced. He used an ultrasonic tool that also acts as a vacuum to break up the lens and suck it out; he also used another tool that filled the area with water. After he made sure the area was clean of cloudiness, the resident injected the lens implant and stitched slits in the cornea with the smallest thread and needle I’ve ever seen. The eye was covered with gauze and a hard patch. The procedure took about 2 hours.

An orthopedic surgeon and a resident did the ankle drain. The patient had a previous injury and had sutures. The resident cut the sutures, and the doctor stuck his finger into the open wound! He felt around the tissue, lifted the foot over a bucket, and washed the wound with saline solution. He injected and vacuumed the solution multiple times. He pointed out a visible nerve in the foot; it looked like an off-white, thin cord. The wound was closed with sutures and the whole leg was wrapped. The procedure took about 15 minutes.

I visited Dr. Krosin on the 7th floor. The orthopedic back office was really cramped and full of computers displaying x-rays. I shadowed him while he met and followed up with two patients, one who had hip replacement surgery a month prior and another with back pain. He was really amicable with the patients and their family, but also efficient. He addressed their concerns on the spot and explained away any confusion. The patients were visibly glad to be in his care. (Afterwards, I got another even bigger and better free burrito in their office!)

The laparoscopic gallbladder removal was performed by three doctors. They inverted the belly button and cut it into quadrants. The reason of going through the belly button is the skin there is relatively thin for all patients. This is where the camera went through. They filled the cavity with air so they had more room to see and work; with the light of the camera inside, the body looked like a red, glowing balloon. They made two other entry points near the gallbladder with their scalpels for their tools. The gallbladder was white-ish green and really distended. They cut and burned near the base of the organ to look for the cystic duct and blood vessel; the gall bladder popped during this process and black bile leaked out. They used the vacuum to suck out the bile. Once they found the vessel and duct, they clamped and cut them. After the gallbladder was free, they cut to detach it from the surrounding area, tossed it into net that passed through the belly button, and removed it from the body. The entry points were stitched. The procedure took about 2 hours.

At about 4pm, my feet were a bit sore and decided to get going. After all the excitement, I was glad I didn’t get kicked out once! Everyone was helpful and willing to answer my questions.

This morning, Dr. Harken started the morning meeting with a discussion about collateral ventilation. This lecture was more difficult for me to follow than the last time I attended. He started by asking the residents to describe SOB (shortness of breath) and how to measure maximal voluntary ventilation. When someone has shortness of breath, the individual breathes too fasts, which has him (or her) blowing off CO2. This results in vasoconstriction in the brain since CO2 is a potent vasodilator. Eventually the individual passes out. Dr. Harken mentioned the ventilation-perfusion (V/Q) ratio and how it’s like a bell curve. V/Q is the ratio of the amount of air getting into the alveoli to the amount of blood being sent to the alveoli. Having adequate ventilation but zero perfusion in the alveoli results in “dead space” while having a V/Q of zero results in a physiological shunt. He made an interesting comment about how someone post-lobectomy does not have SOB and has a V/Q = 1.

The one surgery I observed today was a left breast lumpectomy and sentinel node biopsy. Before beginning, a blue dye called isosulfan blue was injected in the area around the upper half of the patient’s left areola. This dye gets taken up by the lymphatic system and stains the sentinel nodes blue to allow the surgeons to visualize them for removal. Dr. Godfrey was the supervising surgeon and there were two residents who performed and assisted with the surgery. The initial incision seemed fairly small compared to the estimated size of the mass to be removed. There were many small strokes of the Bovie to cut through the fascia and adipose and cauterize blood vessels. I managed to get a good view of the surgery by standing on a stool by the anesthesiologists. When near the anesthesiologists, the anesthesiologist resident gave the patient more medication to prevent her from waking up. He noticed on his monitor that she was slowly starting to breathe on her own by the blue portions of the colored waves on the screen. The yellow wave on the bottom of his screen monitored the patient’s ventilation. I believe it was called a capnogram and measured the amount of CO2 in the patient’s exhaled breath; its waveform is supposed to look like uniform, square mesas with the CO2 levels being between 35-45 mmHg. When the physicians lifted the mass from inside the breast, I saw it was the size of a small lemon. It looked like an unremarkable lump of fatty tissue to my amateur eyes so I was amazed with how they determined whether or not they removed all of the abnormal mass just by looking at the surgical site. Once removing the mass, they inserted stitches to it to note how the mass was oriented when it was inside the body. They then sent the mass to radiology to get it imaged. Pieces of the area surrounding the mass were excised, labeled, and placed in formaldehyde for examination as well. With the mass being the size of a lemon, I was intrigued by the surgeons stitching up the breast incision without putting anything to fill the space left by the mass. I was told eventually that empty space will be filled in by the surrounding adipose. After completing the breast stitching, the surgeons made an incision in the axilla to remove a sentinel lymph node. The blue dye injected earlier was very faint so the lymph node was not very noticeable. It was excised with small strokes of the Bovie, had a stitch inserted for identification, and placed in a biohazard bag for biopsy. The whole procedure took about 3 hours. I was told to come watch the next surgery but I respectfully declined since I did not want to have to leave around when it would have begun. Before leaving, scrub tech Joe showed me the various surgical clamps, cutters, and tweezer-looking instruments that come with their surgical tool sets and briefly showed me where the dirty instruments go to be cleaned. Cleaning and sterilizing the tools requires multiple steps before being usable again.